Effect of Dexamethasone Implant on Subfoveal Choroidal Thickness in Early Period in Vitrectomized Eyes with Diabetic Macular Edema

Association between choroidal thickness and diabetic macular edema: a meta-analysis

AIMS

To evaluate the association between subfoveal choroidal thickness (SFCT) and diabetic macular edema (DME).

DESIGN

A systematic review and meta-analysis.

METHODS

A retrospective or prospective study comparing SFCT in diabetic retinopathy (DR) patients with and without DME was included. The data were collected from published studies retrieved from PubMed, Web of Science, Embase, Ovid Medline, and Cochrane Library. The final search was conducted on July 2, 2023. Heterogeneity was assessed using I2 statistics, and a random-effects model was used for the meta analysis. This study calculated the weighted mean difference (WMD) and 95% confidence interval (CI) for SFCT.

RESULTS

A total of 26 relevant studies were identified, involving a combined sample size of 3201 eyes (1302 DR-DME eyes and 1899 DR-no DME eyes). The results showed no significance between DR-DME and DR-no DME (WMD = - 3.57 μm; 95% CI -26.54 to 19.41 μm; P = 0.76). Sub-analysis based on nonproliferative diabetic retinopathy (NPDR) and proliferative diabetic retinopathy (PDR) subgroups showed that the SFCT of NPDR-DME was significantly thinner than that of NPDR-no DME eyes (WMD = - 19.80 μm; 95% CI - 34.55 to - 5.04 μm; P = 0.009), while there was no significance in SFCT between PDR-DME and PDR-no DME (WMD = - 26.45 μm; 95% CI - 104.00 to 51.11 μm; P = 0.50).

CONCLUSION

The SFCT was thinner in NPDR-DME eyes compared to NPDR-no DME eyes. Thinning SFCT might cause retinal hypoxia, and play an important role in DME occurrence. Additionally, this study highlights the importance of considering DR grades and treatment history when evaluating SFCT between DME and no DME.

Management of treatment-naïve diabetic macular edema patients: Review of real-world clinical data

The high prevalence of Diabetic macular edema (DME) is a real global health problem. Its complex pathophysiology involves different pathways. Over the last decade, the introduction of intravitreal treatments has dramatically changed the management and prognosis of DME. Among the different treatment options, inhibitors of vascular endothelial growth factor (anti-VEGF) and intravitreal steroids implants represent the first-line therapy of DME. We conducted a review of electronic databases to compile the available evidence about the clinical management of DME in a clinical setting, with a special focus on treatment-naïve patients. Anti-VEGF therapies represent a valuable option for treating DME patients. However, many patients do not respond properly to this treatment and, due to its administration regimen, many patients receive suboptimal treatment in real life. Current evidence demonstrated that in patients with DME, DEX-i improved significantly both anatomic and visual outcomes. Besides eyes with insufficient anti-VEGF respond or recalcitrant DME cases, DEX-i can be effectively and safely used in treatment-naïve DME patients as first line therapy. DEX-i may be considered first line therapy in different clinical scenarios, such as DME eyes with a greater inflammatory component, patients with cardiovascular events, vitrectomized eyes, or those requiring cataract surgery. In conclusion, there are still many points for improvement pending in the clinical management of the patient with DME. Since DME treatment must follow a patient-tailored approach, selecting the best therapeutic approach for each patient requires a good understanding of the pathophysiology of DME.

Influence of Intravitreal Therapy on Choroidal Thickness in Patients with Diabetic Macular Edema

OBJECTIVE

This study aimed to analyze the variation in subfoveal choroidal thickness (SFCT) and its relationship with the variation in central macular thickness (CME) in response to intravitreal therapy with an antiangiogenic (anti-VEGF) drug or corticosteroid in type 2 diabetic patients with diabetic macular edema (DME).

MATERIAL AND METHODS

This retrospective study included 70 eyes of 35 patients: 26 eyes received 4-5 intravitreal injections of aflibercept, 26 eyes were treated with a single intravitreal implant injection of dexamethasone, and 18 eyes without DME did not receive intravitreal therapy. SPECTRALIS® optical coherence tomography (OCT) (Heidelberg Engineering, Heidelberg, Germany) was used to measure the SFCT and CME before and at the end of the follow-up period.

RESULTS

The mean reductions in CME were 18.8 +/- 14.7% (aflibercept) and 29.7 +/- 16.9% (dexamethasone). The mean reductions in SFCT were 13.8 +/- 13.1% (aflibercept) and 19.5 +/- 9.6% (dexamethasone). The lowering effects of both parameters were significantly greater in the group treated with the dexamethasone implant (p = 0.022 and p = 0.046 for CMT and SFCT, respectively). Both therapies significantly decreased both CME and SFCT, independent of factors such as age, sex, previous intravitreal therapy, antidiabetic treatment, and the time of diabetes progression. There were no changes in the mean values of CME and SFCT in the untreated eyes.

CONCLUSIONS

SFCT significantly decreased in response to intravitreal therapy with anti-VEGF or corticosteroids, irrespective of age, sex, previous intravitreal therapy, antidiabetic treatment, and the time of diabetes progression. There was a correlation between the changes in CME and SFCT after intravitreal therapy with aflibercept or dexamethasone implantation. SFCT was not a good predictor of the CME response but could be used to monitor the response to treatment. Local intravitreal therapy only affected the treated eye.

Intravitreal Dexamethasone Implant (IDI) Alone and Combined with Navigated 577 nm Subthreshold Micropulse Laser (SML) for Diabetic Macular Oedema

Background: The anatomical and functional changes after intravitreal dexamethasone implant (IDI) alone and combined with navigated subthreshold micropulse laser (NSML) in diabetic macular oedema (DMO) were compared. Methods: Patients with a clinically confirmed diagnosis of non-proliferative diabetic retinopathy (NPDR) and DMO were enrolled in this prospective study and were randomly assigned to two different treatment groups: thirty patients were treated with IDI (IDI group), and the other 30 patients received IDI combined with NSML treatment (combined IDI/NSML group). All patients during a 6-month follow-up underwent best corrected visual acuity (BCVA) evaluation and spectral domain optical coherence tomography (SD OCT). The main outcome measures were: BCVA, central macular thickness (CMT); (3) choroidal vascularity index (CVI), subfoveal choroidal thickness (SCHT); and time to retreatment between IDI at baseline and the second implant in both groups. Results: BCVA, CMT, and SCHT significantly decreased starting from the 1-month follow-up and CVI from 3 months in both groups. The between-group differences were significantly different from 1-month follow-up for BCVA, from 5-month follow-up for CMT and SCHT, and from 4-month follow-up for CVI. The Needed to Treat analysis indicated that six patients would have to be treated with SML after IDI in order for just one person to receive a benefit. Conclusions: the combined treatment showed good anatomical and functional outcomes for the treatment of DMO. In addition, IDI/SML seems to reduce injection frequency over time, improving patients’ quality of life and reducing the socio-economic burden.

Treatment of Macular Edema in Vascular Retinal Diseases: A 2021 Update

Macular edema (ME) is associated with various conditions; however, the main causes of ME are retinal vein occlusion (RVO) and diabetes. Laser photocoagulation, formerly the gold standard for the treatment of ME, has been replaced by anti-vascular endothelial growth factor (anti-VEGF) intravitreal injections. Despite its efficiency, this treatment requires frequent injections to preserve the outcomes of anti-VEGF therapy, and as many patients do not sufficiently respond to the treatment, ME is typically a chronic condition that can lead to permanent visual impairment. Generalized recommendations for the treatment of ME are lacking, which highlights the importance of reviewing treatment approaches, including recent anti-VEGFs, intravitreal steroid implants, and subthreshold micropulse lasers. We reviewed relevant studies, emphasizing the articles published between 2019 and 2021 and using the following keywords: macular edema, diabetic macular edema, retinal vein occlusion, laser photocoagulation, anti-VEGF, and intravitreal injections. Our results revealed that a combination of different treatment methods may be beneficial in resistant cases. Additionally, artificial intelligence (AI) is likely to help select the best treatment option for patients in the near future.